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Published on: August 9, 2024
Clinical Utility of a Precision Medicine Test Evaluating Outpatients with Suspected Obstructive Coronary Artery
Joseph A Ladapo1, Matt Budoff2, David Sharp3
1David Geffen School of Medicine at University of California at Los Angeles.
Insights
The age/sex/gene expression score (ASGES) helps primary care physicians identify obstructive coronary artery disease. Low ASGES scores indicate a lower likelihood of cardiac referral and adverse events, supporting precision medicine in cardiovascular care.
Area of Science:
- Cardiovascular Medicine
- Genomics
- Precision Medicine
Background:
- Evaluating obstructive coronary artery disease (CAD) in primary care is challenging.
- Precision medicine advances, like the blood-based age/sex/gene expression score (ASGES), offer new tools.
- ASGES shows high clinical validity for estimating obstructive CAD likelihood.
Purpose of the Study:
- To assess the clinical utility of ASGES in a community-based registry.
- To measure the impact of ASGES on clinician decision-making for suspected obstructive CAD.
- To evaluate ASGES in stable, nonacute adult patients with suggestive symptoms.
Main Methods:
- Prospective enrollment of 566 patients in the PRESET Registry (NCT01677156).
- Collection of demographics, clinical data, and ASGES results (low ≤15, elevated >15).
- Tracking of Cardiology referrals and cardiac testing post-ASGES, with 1-year follow-up.
Main Results:
- Elevated ASGES significantly increased odds of referral for cardiac testing (aOR=0.18, P<.0001).
- Abnormal findings on advanced testing were rare in low ASGES patients (0%) vs. elevated ASGES patients (14%).
- Low ASGES was associated with fewer major adverse cardiovascular events and revascularizations (1.2% vs. 4.5%, P<.03).
Conclusions:
- ASGES demonstrated clinical utility in evaluating patients with suspected obstructive CAD.
- Low ASGES scores correlated with reduced cardiac referrals, fewer positive work-up findings, and low adverse event rates.
- The study supports using precision medicine, specifically ASGES, in routine cardiovascular care delivery.
Background:
Identifying patients with obstructive coronary artery disease can be challenging for primary care physicians. Advances in precision medicine may help augment clinical tools and redefine the paradigm for evaluating coronary artery disease in the outpatient setting. A blood-based age/sex/gene expression score (ASGES) incorporating key features of precision medicine has shown clinical validity with a 96% negative predictive value and 89% sensitivity in estimating a symptomatic patient's current likelihood of obstructive coronary artery disease. To better characterize the clinical utility of the ASGES and measure its impact on clinician decision-making, a community-based registry was established.
Methods:
The prospective PRESET Registry (NCT01677156) enrolled stable, nonacute adult patients presenting with typical or atypical symptoms suggestive of obstructive coronary artery disease from 21 US primary care practices from August 2012 to August 2014. Demographics, clinical characteristics, and ASGES results (predefined as low [ASGES ≤15] or elevated [ASGES >15]) were collected, as were referrals to Cardiology or further functional/anatomic cardiac testing after ASGES testing. Patients were followed for 1 year post ASGES testing.
Results:
Among the 566-patient cohort (median age 56 years), clinicians referred 26/252 (10%) of patients with low scores vs 137/314 (44%) of patients with elevated scores to Cardiology or advanced cardiac testing for further evaluation (unadjusted odds ratio 0.15, P <.0001; adjusted odds ratio after accounting for clinical covariates = 0.18, P <.0001). Data on 84 patients referred for advanced cardiac testing showed abnormal findings in 0 of 13 (0%) low ASGES and 10 of 71 (14%) elevated ASGES patients. Major adverse cardiovascular events and revascularization were noted in 3/252 (1.2%) patients with low ASGES and 14/314 (4.5%) patients with elevated ASGES score (P <.03).
Conclusions:
In this community-based cardiovascular registry, the ASGES demonstrated clinical utility in the evaluation of patients with suspected obstructive coronary artery disease. Low-score patients were less likely to undergo cardiac referral, were unlikely to have positive findings on further cardiac work-up, and had a low rate of adverse cardiovascular events in 1-year follow-up. Our work provides evidence supporting the value of using precision medicine in the delivery of cardiovascular care.
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